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9. Fee Schedule Incl: Service Type, Base Rate, Mileage, Waiting & Special Charges <br /> IV. NOTARIZED STATEMENTS Fill in Statements as applicable. <br /> E or E1 APPLICANTS <br /> 1, r`r-��.f � � c - , the representative of <br /> Applicant Name <br /> do hereby attest that the <br /> Business Name of Service <br /> above named service meets all the requirements of, and that I agree to comply with, all <br /> applicable provisions of Chapter 304, Life Support and Wheelchair Services. <br /> A-D APPLICANTS <br /> I, M e--'A r4' l , the representative of <br /> Applicant Name <br /> . 6, 1C,4 A.) /`t,� a'��r��fJC" �,o,c, a do hereby attest that <br /> Business Name of Service <br /> the above named service will provide continuous service on a 24-hour, 7-day week basis. I do <br /> ,.,aereby attest that the above named service meets all the requirements for operation of an <br /> ambulance service in the State of Florida as provided in Chapter 401, Part 111, Florida Statutes, <br /> Chapter 64E-2, Florida Administrative Code, and that I agree to comply with all the provisions <br /> of Chapter 304, Life Support Services. <br /> ALL APPLICANTS <br /> I further acknowledge that discrepancies discovered during the effective period of the <br /> Certificate of Public Convenience and Necessity will subject this service and its <br /> authorized representatives to corrective action and penalty provided in the referenced <br /> authority and that to the best of my knowledge, all statements on this application are <br /> true and correct. <br /> JLk4 <br /> APPLICANT IOGNATURE DATE <br /> Before me personally appeared the said M � �)i,dzLt-��._t-i who says that he/she <br /> executed the above instrument of his/her own free will and accord, with full knowledge of the purpose <br /> thereof. Sworn and subscribed in my presence this day of ��201 . <br /> rV^4co.:c- My commission expires: <br /> NOTARY PUBLIC <br /> E€REo tr R Lti�If.LI;R <br /> n N3tary PuNit,fltala of Florida <br /> �'iCIS1i7i6Gi�ii�!'JDsa7366 <br /> My comm.exoles May 23,2014 <br /> .1 F---9-wA <br /> C:\Users\jsalvesen\Documents\American Ambulance Service 2013 Idian river Copcn Application.doc 5 <br /> 108 <br />